Provider Demographics
NPI:1568420099
Name:GORDON, MARK JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAY
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 COLVIN BLVD
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2128
Mailing Address - Country:US
Mailing Address - Phone:716-871-0074
Mailing Address - Fax:716-898-8973
Practice Address - Street 1:978 COLVIN BLVD
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2128
Practice Address - Country:US
Practice Address - Phone:716-871-0074
Practice Address - Fax:716-898-8973
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY TUV004506152W00000X
NYTUV004506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T86340Medicare UPIN
NYCC5182Medicare ID - Type Unspecified